Student Support Services
423-798-1635 Fax: 423-787-8494 1-800-729-0256 ext. 5635
Student Support Services is funded by the U.S. Department of Education for $290,000. Certain personal
information is required; however, the information provided will be held in strictest confidence.
***NOTICE - To be considered for Student Support Services, applicants MUST attach a copy of the
parent’s 2010 tax return when submitting this application. Applications lacking tax documentation are considered incomplete and will not be reviewed. If parents did not file taxes for 2010 please call a program representative at the number listed above for information regarding completion of an Income Verification Form.
GENERAL INFORMATION (Please Print)
Social Security Number_________________________________ Date of Birth________________________
College Box Number #__________ Home Phone #________________Cell Phone #_____________________
For the 2011-2012 academic year, the applicant will be: _____ an on Campus Resident _____a Commuter
Local address (if commuter)__________________________________________________________________
Citizenship: (Check one)
____U.S. Citizen ____Territory Resident ____Permanent Visa ____Other (specify)
Previous participation in other Federal TRIO programs:
____Educational Opportunity Centers
Previous college(s) attended:______________________________________________________________________
FINANCIAL AID INFORMATION
Have you applied for financial aid? ____Yes ____No If so, are you currently receiving aid? ____Yes ____No
Do you have a learning disability of any kind? ____Yes ____No
If so, have you or do you intend to inform the campus Academic Resources Center (ARC) of your learning disability?
Please list or describe your learning disability ________________________________________________________
Please check all areas in which you need assistance, instruction, or information.
____Academic Advising ____Graduate School Info/Visit ____Scholarships
____Career Guidance ____Mentoring ____Computer Loan
____Computer Skills/Assistance ____Personal Counseling ____Informational Workshops
____Tutoring ____Book Loan ____Other_________________
____Cultural Enrichment ____Study Skills Enhancement
____Financial Aid Information ____Student Success Skills
Additional information you wish to share that may assist program staff in helping you:
I understand that I must utilize program services and/or activities. Prolonged inactivity (for longer than two semesters) may result in forfeiture of participation in the program.
In addition, this is to certify that I agree to waive my rights under the Family Privacy Act (Buckley Amendment), and agree to permit the Student Support Services Program staff to access academic history and financial aid and information. I understand that this information will be held in strict confidentiality and only utilized in determining eligibility and reporting performance.
I also give my permission for Tusculum College SSS to use my likeness or photographic images for program-related publications, social media, and/or public relations materials. Such items may include: newspaper releases, Facebook posts, web site images, and promotional brochures. I understand that these items will be used by Tusculum College’s Student Support Services program personnel solely for the purposes of promoting the program.